MEDICOLEGAL CERTIFICATE

NAME:
ADDRESS:
AGE:
SEX:
CIVIL STATUS:
DATE ADMITTED:
ROOM NO.:
ALLEGED PLACE, DATE, AND TIME OF INFLICTION:
DATE AND TIME OF EXAMINATION:

FINDINGS:

CONCLUSION:

REMARKS:

Respectfully submitted:
Stephen Strange, M.D., LL.B.
Lic. No. 11042016